Inspection Reports for Ivy Park at Santa Rosa

The inspection was an unannounced 1-Year Required annual inspection conducted to evaluate compliance with licensing requirements for the assisted living and memory care facility.

The facility was found to be clean, orderly, and compliant with safety and health regulations. All staff and resident documentation were in order, emergency supplies and disaster preparedness were adequate, and no deficiencies were cited during the visit.

Unannounced 1-Year Required Visit to evaluate compliance with regulations for an assisted living and memory care facility.

The facility was found to be clean, well-maintained, and compliant with regulations including infection control, emergency preparedness, and resident care documentation. No deficiencies were cited during the visit.

The visit was an unannounced case management inspection triggered by a report of sexual assault abuse involving a resident at the facility.

The investigation found that a resident reported a sexual assault by an unknown suspect. The administrator notified police and the resident was transported to the hospital. No deficiencies were cited during this inspection.

The complaint involved a sexual assault reported by resident R1 on 1/31/2024. The suspected abuser is unknown. The facility reported the incident to police and the resident's responsible party. Hospital discharge information and police report were not available at the time of inspection.

The visit was an unannounced case management inspection regarding an incident report received on 2024-01-08 involving alleged abuse of a resident by self-neglect, which resulted in hospitalization.

The investigation found that the resident had jumped from a second-floor window resulting in a fractured back and hospitalization. The facility took immediate corrective actions including fitting safety window restrictors and conducting additional staff training on suicide precautions. No deficiencies were cited during this inspection.

The complaint involved abuse of resident (R1) by self-neglect leading to a 72-hour hold and hospitalization. The incident was cross-reported to police (report #24-271). The resident remains hospitalized with a fractured back and will not be returning to the facility. The complaint was investigated with no deficiencies cited.

The visit was an unannounced case management inspection conducted in response to an incident report received on 12/15/2023 regarding alleged abuse of a resident in the form of theft of a cellphone.

The investigation found that the resident's cellphone was missing and presumed stolen after staff accidentally washed it and returned it to the resident. The facility conducted an investigation, cross-reported the incident to appropriate parties, and filed a police report. No deficiencies were cited during this investigation.

The complaint involved alleged theft of a resident's cellphone. The incident was substantiated by the facility's investigation and police report filing. The resident's apartment was searched without locating the phone, and the cellphone carrier was unable to locate it remotely.

The visit was an unannounced case management inspection conducted in response to an incident report received on 2023-10-06 regarding a resident who was found missing from the facility.

The investigation found that resident R1, diagnosed with dementia and residing in Memory Care, eloped from a locked memory care unit and was later found at a hospital emergency room with no injuries or new diagnoses. The facility increased staff monitoring and conducted additional staff training following the incident. A deficiency was cited for failing to meet the requirement of adequate direct care staff to support residents' needs.

The visit was complaint-related, triggered by an incident report about resident R1 eloping from the facility. The resident was found safe at a hospital ER. The complaint was substantiated by the cited deficiency.

The inspection was an unannounced Case Management-Incident visit to discuss three incidents reported by the facility, including a missing resident's jewelry, a resident's fall resulting in a hip fracture, and a rodent sighting in an apartment.

No deficiencies were observed or cited during the inspection. The facility took appropriate actions including contacting responsible parties, reassessing the resident after the fall, and eradicating the rodent issue with pest control measures.

The visit was complaint-related to three incidents: missing jewelry reported on September 20, 2023; a resident's left hip fracture from a fall on September 25, 2023; and a rodent sighting on September 27, 2023. The facility responded appropriately to each incident. No deficiencies were cited.

The inspection was an unannounced Case Management - Incident visit conducted to investigate an incident involving inappropriate photos of two residents sent via cellular device and email to the Administrator.

The Licensing Program Analyst found that a staff member sent inappropriate photos of two residents to the Administrator, which posed an immediate health, safety, and personal rights risk. The staff member was written up and the Administrator was educated on the prohibition of resident photography on personal cell phones.

The inspection was conducted as a Case Management-Incident Inspection following an incident report of a resident fall, injury, and subsequent hospital visit.

No deficiencies were observed or cited during the inspection. The resident was reported to be doing well and prescribed medication for pain. The Care Plan will be updated with the family.

The visit was complaint-related due to an incident report forwarded on June 10, 2023, concerning a resident fall and injury. The complaint was investigated and no deficiencies were found.

The inspection was conducted as a Case Management-Incident Inspection following incidents submitted to the Community Care Licensing on April 22, 2023, and May 5, 2023, including a resident-to-resident altercation.

The facility was found to have followed all proper procedures related to the incidents reviewed, including confirming that a resident was not on a Special Diet and that care plans will be updated for involved residents. No deficiencies were observed or cited during the inspection.

The visit was complaint-related, triggered by incident reports submitted on April 22, 2023, and May 5, 2023. The complaint was investigated and found to be unsubstantiated as no deficiencies were cited and residents had no recollection of the altercation.

Unannounced complaint investigation visit conducted in response to an allegation that staff interfered with resident visiting at the facility.

The investigation found the allegation to be unfounded after reviewing records, conducting interviews, and observing the resident. No one was denied entry to visit the resident, and no deficiencies were observed during the inspection.

The allegation that staff interfered with resident visiting was investigated and found to be unfounded, meaning the allegation was false, could not have happened, and/or was without a reasonable basis.

The inspection was an unannounced required 1-year inspection focused on infection control practices and procedures at the facility.

The facility was found to be clean and in good repair with sufficient food supplies, operational safety equipment, and proper infection control measures including staff training and COVID-19 precautions. No deficiencies were observed during the inspection.

The inspection was a case management visit conducted due to a self-reported SOC341 incident received by Community Care Licensing on 2022-12-20. The facility conducted an internal investigation and reported the incident to the Santa Rosa Police Department.

No deficiencies were cited during the inspection. The Licensing Program Analyst will follow up by requesting the police report related to the incident.

The visit was complaint-related based on a self-reported incident (SOC341) received on 2022-12-20. The facility conducted an internal investigation and reported the incident to the police. Follow-up includes requesting the police report.

The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 08/16/2022 regarding neglect, failure to address change in resident's condition, and failure to report incidents including death, fall, and pressure injury.

The investigation found no preponderance of evidence to substantiate the allegations of neglect, failure to address change in condition, or failure to report incidents. The allegations were determined to be unsubstantiated and no deficiencies were cited during the inspection.

The complaint involved allegations of neglect/lack of care causing an unstageable pressure injury, failure to address a resident's change in health condition, and failure to report death, fall, and pressure injury. The investigation concluded all allegations were unsubstantiated.

Unannounced complaint investigation visit conducted in response to multiple allegations including resident falls, skin tears, delayed medical attention, physical abuse, hygiene neglect, improper medical documentation, malnutrition, and failure to inform representative of condition changes.

The investigation found one allegation substantiated regarding failure to arrange timely podiatric care resulting in excessive toenail length and dry cracked skin, posing immediate risk to resident health. Other allegations including unwitnessed fall, skin tears, delayed medical attention, physical abuse, hygiene neglect, improper documentation, malnutrition, and failure to inform representative were found unsubstantiated or unfounded based on evidence reviewed.

Complaint investigation was conducted based on allegations received on 05/31/2022. The complaint included multiple allegations such as unwitnessed fall, skin tears, delayed medical attention, physical abuse, hygiene neglect, improper medical documentation, malnutrition, and failure to inform resident's representative. The investigation concluded the complaint was partially substantiated (podiatric care issue) and partially unsubstantiated or unfounded for other allegations.

The inspection was conducted as a Case Management Inspection regarding an incident report received by Community Care Licensing on 2022-06-09 involving a resident eloping from memory care.

The Licensing Program Analyst observed that exits to outdoor patio areas and the front entrance were armed with alarms, but a resident was able to exit one alarmed door and one delayed egress door, posing an immediate health and safety risk. Deficiencies were cited related to care of persons with dementia and safety measures for wandering behaviors.

Inspection was triggered by an incident report of a resident eloping from memory care on June 8, 2022. The complaint was substantiated as deficiencies were found.

The visit was an unannounced Post Licensing Inspection conducted to evaluate the facility's compliance following licensing.

The facility was found to be clean and in good repair. Infection control measures including COVID screening and staff vaccination were in place. Medications and toxins were securely stored. However, a written plan was requested to provide fire extinguisher access to memory care staff by July 1, 2022.

The visit was conducted as a Case Management - Other type of visit, specifically to return the file for a resident (R1).

The Executive Director reviewed the contents of the resident file and confirmed it was returned complete and undamaged per regulation. An exit interview was conducted with the administrator and a copy of the report was emailed to the facility.

The inspection was an unannounced pre-licensing visit conducted to evaluate the facility for initial licensing approval.

The facility was found to have appropriate furnishings, safety features such as grab bars, smoke alarms, sprinkler systems, and locked medication storage. Staff CPR and First Aid certifications were current, and sufficient food supplies were observed. No deficiencies or violations were noted in the report.

The visit was an office type evaluation related to a Change of Ownership (CHOW) application, including a Component II telephone call to verify the applicant and administrator's understanding of Title 22 regulations and facility operation.

The applicant and administrator successfully completed Component II via telephone, confirming understanding of facility operation, staff qualifications, program policies, and application document review including criminal record clearance, health screening, and other licensing requirements.